ke/bv/rg/nl
Date : 00.00.00

Name of the Patient : Abc XyzKudlmn / M / 30 yrs.
Referred by : Dr. Abc Xyznna.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE (left more than right) with paresthesias (on & off) since 6 years.
Alleged H/O vehicular accident with fall prior to this.

EXAMINATION :

M.R.I of the lumbo-sacral spine was performed using the following parameters :

5 mm thick T1 Weighted and T2 Weighted sagittal images.

5 mm thick T1 Weighted and T2 Weighted axial images.

OBSERVATION :

The L4-L5 facet joints show mild degenerative changes with minimal effusion bilaterally. There is also hypertrophy of the facet joints bilaterally at the L5-S1 level.

A small posterior disc bulge is seen at the L4-L5 level. The L4-L5 intervertebral disc shows loss of water content.

The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the L1 level and the thecal sac terminates at the S1 level.




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The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :

17.0 mm at L1-L2
17.0 mm at L2-L3
14.0 mm at L3-L4
14.0 mm at L4-L5
14.0 mm at L5-S1.

IMPRESSION :

1. Facetal arthropathy at the L4-L5 level with minimal effusion bilaterally and degenerative changes in the L5-S1 facet joint.

2. A small posterior disc bulge at the L4-L5 level.